HomeMy WebLinkAboutKNIK VIEW BLK 2 LT 5K n 1* k View
Block 2
Lot 5
#051-031-36
Municipality of Anchorage Page of
DEPARTMENT OFF HEALTH AND HUMAN SERVICES
ENVIRONMENTAL SERVICES DIVISION
P.O. Box 196650 • Anchorage, Alaska 99519-6650 ® Telephone: 34:3-4744
On -Site Wastewater Disposal System and/or Well Inspection Report
Permit Number: 0 0 I PID Number:
Name: r
t L ? �lA
Wastewater System: %New ❑ Upgrade
Address:
ABSORPTION FIELD
Phone: �qq q
a7 1— �I-l��
No. of Bedrooms:
�
Dee Trench ❑ Shallow Trench ❑ Bed ❑ Mound ❑ Other
� p
LEGAL DESCRIPTION
Soil Rating:
1°
Depth from on I?inal grade:
FtTotal
GPU/S . .
CEJ,
Lot: Block: SuPdivisi n:
2 I
Depth to pipe bottom from /original grade:
_ y t Ft.
_
Gravel depth beneath pipe
7 Ft.
Township:
Range: Section:
Fill added above original grade:
pI/Ft.
e
Gravel length: ' /
YD Fl.
WELL: New ❑ Upgrade
Gravel width: 6
lines:
Numberofistancelbeetween
Dlines :
Ft.
I
N A Fl.
Classification (Private, A,B,C):
_
Total Depth:
Ft.
Cased To:
Ft.
Total absorption area:
SC). Ft.
Pipe material: P610
—030
Driller:
Date Drilled:
Static Water Level:
Installer i
Date installed:
Yield:
Pump Set at:
I
Casing Height Above Ground:
TANK
GPM
Ft.
Ft.
SEPARATION
DISTANCES
Septic ❑ Holding ❑ S.T.E.P.
To
Septic
Absorption
Lift
Holding
Public/Private
Manuf cturer:
Capacity in gallons:
From
Tank
Field
Station
Tank
Sewer Lines
,.,
Well -Material:
zo,I *
ZDD
p r
Number of Compartments:
Watere
f+—
JLL�lLot
—
—
LIFT STATION
I
Size in gallons:
Manufacturer: /
Line
1D41l
—
Foundation
/D �
I�
p
_..__
-�
"Pump on" level at:
"Pumpmp off'LI
High water alarm at:
Curtain
/DO �k
1 D�
Pump Make &Mode
lectrical Inspections performed by:
Drain
Remarks:
BENCH MARK
Location and Description:
Assumed Elevation:
ENGINEER'S SEAL
®®, O
NIKOF
e q•i�o�
��® ��
�
s
®'� ern •
Inspections performed by: Dates: 1s s 15C 98
�•� .,. saws 09a..e..�.o
S•
2nd ✓
® aeees..a a..n a •..s ..
'
//rlg
Department of Heal and Services appr`OyZI
®��,� KennCE17116 u �• fir.
�e :
)Uman
Q eq °' :��Y,� '���
.e a N
Reviewed and approved by: �' Date: 19-46-
�R%FE5S14NPx
�,`�'�Ra�.,w::.
72-013 (Rev. 9/91) MOA 25
2
AS -BUILT SYSTEM DETAILS/SITE PLAN Permit SW980097
KNIK VIEW S/D, LOT 5, BLOCK 2 PID#051-031-36
T
1
YCAL.S.T.
C❑\�
0� TH 98-1--
RESERVE STEM 011c) M
E C❑
P MA SYS M
y
o SEPTIC
A -C=48.3'
COMPUTED,
BOUNDARY:
W
B -C=232,5'
STAKING,
SE.WARD
_ wd
A -D=43,3'
SEWARD
DATE 10/30Z
o
B -D=26.4'
GRID: NW1557
ACAO FILE:
98028.DWG
A -E=35.0'
B -E=34.4'
N
A -F=23.9'
B -F=72,3'
SEPTIC
s ��OF' AL4 �
/ V �1
9 TI_I * I
0 KENNETH M. D F /
`� CE -7116 4,�
ftrL'SSIO; Aw
SEPTIC
IS9 �
� 9
V
/ i
BDRM
;FD
/
a ,
n ; /
,
� G ,
LOT
VACAN
SCALEI 1" = 50'
o=
r�
a
ORIGINAL GRADE
FILTER FABRIC,,". VARIES
L
\90.05 90.04 V
SEWER ROCK 4.C'
X0.04 II6,04 86.04
�— 40'
PREPARED FOR: —� SCALE NTS 80.04 BNN
MICHAEL QUINN CONSTRUCTION
D. uux 772641
EAGLE RIVER, ALASKA 99577
IIILDBOOKS
COMPUTED,
BOUNDARY:
_
DRAM: KIVID
STAKING,
SE.WARD
CHECKED: KIAD
ASBUILT:
SEWARD
DATE 10/30Z
0'iG_ FILE
--
GRID: NW1557
ACAO FILE:
98028.DWG
COs No.: 98028
�Al LU-) ENGINEERING
20141 PTARMIGAN BLVD.
EAGLE RIVER, AIC 99577-8736
907)696-6111/FAX (907)696-8111
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
P.O. BOX 196650, 825 "L" STREET, ROOM 502
ANCHORAGE, ALASKA 99519-6650
ON-SITE WASTEWATER DISPOSAL SYSTEM PERMIT
PERMIT NUMBER:SW980097
DESIGN ENGINEER:KND ENGINEERING
OWNER NAME:SINGLETON DEREK V & MICHELE M
OWNER ADDRESS:MIKE QUINN CONSTRUCTION
PARCEL ID:05103136
LEGAL DESCRIPTION:
KNIK VIEW BLK 2 LT 5
LOT SIZE: 20000 (SQ. FT.)
NUMBER OF BEDROOMS: 3 THIS PERMIT: 3
THIS PERMIT IS FOR THE CONSTRUCTION OF:
DISPOSAL FIELD /SEPTIC TANK SYSTEM
ALL CONSTRUCTION MUST BE IN ACCORDANCE WITH:
Il�i''UL:cAM
PAGE 1 OF
DATE ISSUED: 5/06/98
EXPIRATION DATE: 5/06/99
1. THE ATTACHED APPROVED DESIGN.
2. ALL REQUIREMENTS SPECIFIED IN ANCHORAGE MUNICIPAL CODE CHAPTERS
15.55 AND 15.65 AND THE STATE OF ALASKA WASTEWATER DISPOSAL
REGULATIONS (18AAC72) AND DRINKING WATER REGULATIONS (18AAC80).
3. THE ENGINEER MUST NOTIFY DHHS AT LEAST 2 HOURS
PRIOR TO EACH INSPECTION. PROVIDE NOTIFICATION BY
CALLING 343-4744 ( 24 HOURS ) . (NOT REQUIRED FOR WELL ONLY PERMIT)
4. FROM OCTOBER 15 TO APRIL 15 A SUBSURFACE SOIL
ABSORPTION SYSTEM UNDER CONSTRUCTION DURING FREEZING
WEATHER MUST BE EITHER:
A. OPENED AND CLOSED ON THE SAME DAY
B. COVERED, SEALED AND HEATED TO PREVENT FREEZING
5. THE FOLLOWING SPECIAL PROVISIONS.
SPECIAL PROVISIONS:
RECEIVED
ISSUED BY
DATE: j$
DATE:
rKND ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577-8736
907)696-6111/FAX (907)696-8111
April 22, 1998
Municipality of Anchorage
Dept. of Health & Human Services
On -Site Services Section
P. O. Box 196650
Anchorage, Alaska 99519-6650
Subject: New Sewer Permit - Knik View S/D, Block 2, Lot 5
Gentlemen:
On April 9, 1998, we excavated a testhole for the subject property. The results of this
test and water monitoring are attached.
We propose to install a 5' wide shallow trench. The testhole indicated no water, and
based on other area testholes and monitoring we have no concerns that water may
be found later on in the year. Additional fill will be placed over the system to
provide a minimum of 3' of cover when complete if required. There is sufficient
area for both the primary and reserve fields within the radius of the testhole for the
proposed three bedroom single family residence.
All lots are served by community water and there are no public or private wells
within 200' of our proposed system location. There is neither surface water within
100' nor any known curtain drains within 50'. We do not expect that there will be
any adverse effect on adjacent lots by the development of this system.
If you have any questions, please contact me at 696-6111/FAX 696-8111.
Respectfully submitted,
KTI' 1J Engineering
RECEIVED
APR 2 2 1998
MUNICIPALITY OF ANJ(,K)RAG
Kenneth M. Duffus, P.E. FNVIRONMENTAL SERVICES DIVISION
attachments: On -Site Well and Sewer Application
Wastewater Absorption System Details/Site Plan
Soils Log/Percolation Test
WASTEWATER DISP❑SAL SYSTEM DETAILS/SITE PLAN
KNIK VIEW S/D, LOT 5, BLOCK 2
NO PUBLIC WELLS WITHIN 200' OF
PROPOSED SYSTEM.
NO PRIVATE WELLS WITHIN 200' OF
PROPOSED SYSTEM EXCEPT AS NOTED.
NO SEPTIC SYSTEMS WITHIN 200' OF
PROPOSED WELL EXCEPT AS NOTED.
OF AL4
AV < t� �
'49TH
KENNETH N1, ..
16 4'
AV
lk
7F SSIo�Pti
DESIGN DETAILS
3 BDRM X 150 GPD = 450 GPD
450 GPD/1.2 GPD PER SQ. FT. = 375 SQ. FT
(375/(5')) X 0.5(RF) (4.0' GRAVEL) = 37.5 FT. TRENCH
Total depth of system Is 8.0' from orlglnal grade.
Total depth of gravel below distribution pipe is 4.0'
N❑TES+
1. USE' 1000 GALLON SEPTIC TANK. INSULATE TANK IF <4' COVER,
2. INSULATE TRENCHES WITH 2' HD BURIAL. FOAM..
3, CONTRACTOR WILL ENSURE MAXIMUM 21 SLOPE INTO SEPTIC TANK.
4. ADDITIONAL FILL WILL BE ADDED OVER SYSTEM TO ACHIEVE
MIN. 3' COVER IF REQUIRED.
5. ALL LOTS SERVED BY PUBLIC WATER.
PREPARED FOR;
MICHAEL_ QUINN CONSTRUCTION
P.D. BOX 772641
EAGLE RIVER, ALASKA 99577
TLD BOOKS
CCMPUIE:
BOUNDARY Sl- WARD _.._.
STAKING SEWARD
_ DRAWN KMD ,-
CHECKED:KMD
ASBUI
BWG. rIE
BATE
GRID
NW
ACAD ;u.I' 98028.0WG
JOD Nu:
-155
98028
SCaIeI 1'= 100'
1_L�AVI 1L2J ENGINEERING
20441 PTARMIGAN BLVD.
EAGLE RIVER, AK 99577--8736
907)696 -6111/PAX (907)696--6111
-•'CNWE fA 4` w l j `
Municipality of Anchorage *� 49111*••• h,)
DEPARTMENT OF HEALTH & HUMAN SERVICES "'' "''° "'' "'• ""'•'
825 "L" Street, Anchorage, Alaska 99502-0650 .z.'.�, ; �. ....�...
9 t Kennefh M. us
SOILS LOG — PERCOLATION TEST Ja'4 CE/116
/�
"80FESSIO' In �aD
PERFORMED FOR 'I V-1 cc,,, __ DATE P F H F O R M E D:
LEGAL DESCRIPTION:{�1IC.� Township, Range, Section.
SLOPE SITE PLAN
DEPTH / / �F _
IFEFTI Or!/CLstics /CGrC7iS`i rdO iCc I___i
2 0
3 j
,.t
4 p.
5
►Q
Lir
12
13- �\
14
15-
16-
17-
18-
19
ltd/Sam G1" coat -5e'
ti✓Orvo
3�ouq%�i
WAS GROUND WATER
ENCOUNTERED? AL
S
IF YES, AT WHAT L
O
DEPTH? _ P
E
Depth to Water Alter
Monitoring? / Date:
Reading
Date Gross
Time
Net
Time
r'.
Net
Drop
T
--
2
/O -'07
Z Ani
Z
_
/D ,
"„ '
( _
j7
D
„
1
Reading
Date Gross
Time
Net
Time
Depth to
Water
Net
Drop
--
2
/O -'07
Z Ani
Z
_
/D ,
"„ '
( _
j7
D
„
20 -�
PERCOLATION RATE _?' / (mmulesnnch) PERC HOLE DIAMETER
TEST RUN BETWEEN FT AND —�—/ FT
COMMENTS
PERFORMED BY. 1}LILL/_C�'(//7JJ�J��.CZ� — - I A �� LZ 5 CERTIFY THA TF IS TEST WAS PERFORMED IN
ACCORDANCE WITH ALL STArE AND MUN PAL GUIDELINES IN EFFECT ON THIS DATE. DATE.
72-008 (Rev. 4185)
Municipality of Anchorage
Development Services Department
Building Safety Division
/ On -Site Water and Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
FOR A SINGLE FAMILY DWELLING
Parcel I.D. 051-031-36 COSA # d 9 O I.50
Expiration Date: 6-41-10
1. GENERAL INFORMATION
Complete legal description Knik View SID Block 2 LOU
Location (site address) 22600 Inlet Vista Drive Chuaiak AK 99567
Current Property owner(s) Trent & Heidi Thomas Day phone 688-4182
Mailing address
Lending agency
Mailing address
Real Estate Agent
Mailing Address
22600 Inlet Vista Drive Chugiak AK 99567
Unless otherwise requested, COSA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well ❑
Individual Water Storage ❑
Community Class Well ❑
Public Water System
Day phone
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual On-site
Individual Holding Tank ❑
Community On-site ❑
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Onsite Systems
Approval (COSA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of On -Site Systems Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also issues COSAs upon request to homeowners. Certificates of On -Site Systems Approval
are valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued
with new water sample results. (Certificates may be reissued for a period of up to one year with vafid water
samples.) Certificates are valid for one year for properties served by Class A or B wells or a public water system.
The Municipality of Anchorage Is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, 1 verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm Pannone Engineering Services, LLC Phone 272.8218
Address P.O. Box 102954, Anchorage, AK 99510
Engineer's Printed Name Steven R. Pannone, P.E. Date 611/09
Engineers Comments: In conducting an adequacy test, l attempt to provide a thorough, conscientious engineering analysis of the system in
accordance with MOA DSD Guidelines & Regulations. The reported results describe the performance of the system under the conditions
encountered at the time of the test and separation distances measured to readily identifiable features.
The operational life of all wells and septic systems depend on the local soil condition, ground water
levels that may fluctuate during the year, and the water usage of the family being served by the system.
These conditions are outside the control of the evaluator of this system. All systems eventually fail and
satisfactory lest results do not guarantee future performance of the system, nor do they guarantee that
there are no hidden defects or encroachments. PES can therefore not provide any warranty for future
performance nor give any estimate of how long the system will continue to meet the operational
requirements of the MOA DSD. The content of this report is for the sole benefit of the owner listed
above. Any reliance upon or use of this report by any other person or party is not authorized nor will it
confer any legal right whatsoever.
5. DSD SIGNATURE
_J�f Approved for 3 bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulations: .
ON-SITE
WASTEWATER "
Attachments:
COSA Checklist X
Septic System Advisory
Well Flow Advisory
Nitrate Advisory
Arsenic Advisory
Maintenance Agreements
Supplemental Engineer's Report
Other
By a&.�Original Certificate Date: G — q-09
(R" IINS)
Municipality of Anchorage
• Development Services Department
Building Safety Division
' On -Site Water & Wastewater Program
4700 Bragaw Street
P.O. Box 196650
Anchorage, AK 99519-6650
www.muni.org/onsite
(907) 343-7904
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL CHECKLIST
Legal Description: knik Vista Block 2 Lot 5 Parcel ID- 051-031-36
A. WELL DATA
Well type AWWU
Total depth
Date of test
Static water level
Well production
WATER SAMPLE
Coliform —L
If A, B, or C provide PW SID #
Sanitary seal (YIN)
Cased to ft.
ELL LOG
g.p.m.
00 mL Nitrate mg/L
Well Log (YIN)_
Wires properly pro ed (YIN)
Casing t (above ground) in.
INSPECTION
ft.
g.p.m.
Other bacteria Conies/100 mL
Arsenic! ugll Date of sample: _ Collected by. _
B. SEPTICIHOLDING TANK DATA -0- S'ac COVAfvw-ni-5 5t.c-0 On -
Tank Type/Material Anchorage Tank Steel Date installed 5.15.98
Tank size 1000 gal. Number of Compartments 3 Cleanouts (Y/N) Yes
Foundation cleanout (Y/N) Y Depression over tank (YIN) N High water alarm (Y/N) WA
Date of pumping 611109 Pumper X& Pumping
C. ABSORPTION FIELD DATA
Date installed 5115198 Soil rating (g.p.d.lfe or felbdrm)125 System type Deep Trench
Length 40 ft. Width 5 ft. Gravel below pipe 4 ft.
Total depth 8.25 ft. Eff. absorption area 400 ft Monitoring tube Y Depression over field N
Date of adequacy test 6.1.09 Results (Pass/Fail) Pass For 3 bedrooms
Fluid depth in absorption field before test 0.00 in. Water added450 gal. New depth0.00 in.
Elapsed Time: 0 min. Final fluid depth Dry in. Absorption rate >= 450+ 9-p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) No If yes, give date
D. LIFT STATION
Date�t led
'Pump on" level aC=� In.
Datum \
E. SEPARATION DISTANCES
Size In gallons
'Pump off" level at
tested
SEPARATION DISTANCES FROM WELL ON
Septic tank/tift station on lot
Absorption field on lot
Public sewer main
Sewer/sept s1rviceline
containment areas
Manhole/Access (YIN)_
In. High water alarm level at
Meets alarm & circuit reo
On -'adjacent lots
On adjacent Idts
Public sewer ma
Holding tank _
Manure/animal excrete storage areas
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 10+ Propertyline 1D+ Absorption field 5+
Water main 25+ Water service line 25+ Surface water 100+
Wells on adjacent lots 200+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10+ Building foundation 10+ Water main 25+
Water Service line 25+ Surface water 100+ Driveway, parking/vehicle storage 10+
Curtain drain None Observed Welts on adjacent lots 200+
F. COMMENTS
R'S CERTIFICATION
G. rev reify t at I have
determined
t the above I stems are in r r ' TH Y"♦
�i
ew of
I certify that 1 have determined through field Inspections and ; f 49— .a 00
Municipal y �.._. ...0
conformance with MOA COSA guidelines in effect on this date. •"°'•;' "' .. ...........
�c� Sleven R. Ponm)r.,/•u•
��C)1S No CE eia, Ems`':
Engineer's Printed Name Steven R. Pannone. P.E. ♦ .
• ,� ,...•• c > .
Date All In 9 eee��CrF SIo':•'�
aaagaaa���
COSA Fee $ D w Waiver Fee $
Date of Payment % (I / ci Date of Payment
Receipt Number f2ra 6 ( Receipt Number
(Rev. 11105)
4
Municipality of Anchorage
Development Services Department
Building Safety Division
On -Site Water and Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Ar
r°.°c 'ee4'te
CERTIFICATE OF HEALTH AUTHORITY APPROVAL
all
FOR A SINGLE FAMILY DWELLING
-Parcel I.D. 051-031.36 HAA # 650.E
Expiration Date: 7/zl lec
1. GENERAL INFORMATION
Complete legal description Knik View, Block 2. Lot 5
Location (site address or directions) 22460 Inlet Vista Drive
Current Property owner(s) _Derek Singleton Day phone 688-3008
Mailing address
Lending agency
Mailing address
-- - —Real Estate Agent
Mailing Address
-Bridget------- —
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual Well ❑
Individual Water Storage ❑
Community Class Well ❑
Public Water System 0
Day phone
phone-nfa — —
TYPE OF WASTEWATER DISPOSAL:
Individual On-site ID
Individual Holding tank ❑
Community On-site p
Public Sewer ❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an Independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on-site wastewater disposal and/or water
supply system. DSD also Issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on-
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on-site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm KND ENGINEERING, Inc. Phone (907) 868-3791
Address 20441 Ptarmigan Blvd., Eagle River, AK 99577
Engineer's Printed Name Kenneth M. Duffus
Engineer's Comments:
This investigation was completed in compliance with
ADEC and MOA regulations. The assessment of the
condition of the well and septic applies only to the
conditions as of the day tested. The flow and absorption
rates may change due to subsurface conditions that
may not be observed from the surface, changes in
land use, local soil characteristics, groundwater levels
that may fluctuate during the year and the water usage
of the family being served by the system. The operational
life of all well and septic systems are subject to these
various and dynamic characteristics and are outside the
control of the evaluator of the well and septic system.
Therefore, KND can not give any estimate of how long a
system will fdnctiot satisfactory for cbrrenf m future
occupants or can KND guarantee that no unseen
encroachments, deficiencies or discrepancies exist.
5. DSDSIGNATURE
Approved for 3 bedrooms.
:2 : • 0�-S�jE O • C
'. vwjpgZE`NA M
RA •
Disapproved.
_ Conditional approval for bedrooms, with the following
Attachments:
HAA Checklist X Maintenance Agreements
Septic System Advisory Supplemental Engineer's Report
Well Flow Advisory Other
By: Original Certificate Date::71.;Lfkf
(Rev 011021
Municipality of Anchorage e
• Development Services Department
Building Safety Division
On Site Water 8 Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99511.6650
www.d.anchorage.ak.us
(907) 343-7904
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: Knik View, Block 2. Lot 5 Parcel ID: 051.031.36
A.- WELLOATA-
Well type AWWUIMOA If A, B, or C provide PWSID #_ Well Log (Y/N)
Date completed
Total depth ft.
Data of test
Static water level
Well production
Sanitary seal (Y/N) _
Cased to ft.
FROM WELL LOG
WATER SAMPLE RESULTS:
ft.
Wires properly protected (Y/N)
Casing height (above ground)
AT INSPECTION
ft.
g.p.m I " g.p.m.
Coliform colonies/100 ml. Nitrate mg.A.
Arsenic: mg.A. Date of sample:
B. SEPTIC/HOLDING TANK DATA
Other bacteria coloniesl100 ml.
Collected by: KND Enolneerino
Tank Type/Material Steel Date Installed fill SM8
Tank size 1000 gal. Number of Compartments Cleanouts (Y/N) X
Foundation cleanout (Y/N) Y_Depression over tank (YM) N_High water alarm (YIN) N9
Date of pumping Schedule We _ Pumper McDonalds
C. ABSORPTION FIELD DATA
Date installed S/15AI8 Soil rating (g.p.dJfe or fl2/bdnn) jj System type`Deeo Trench
Length 40 ft. Width 5 ft. Gravel below pipe 4 ft.
Total depth AWfl. Eff. absorption area _I_SD fe Monitoring tube Y Depression over field N
Date of adequacy test 7MV05 Results (Pass/Fall) Pass For a bedrooms
Fluid depth In absorption field before test 0 in.
Elapsed Time: 15 min. Final fluid depth Q in.
Water added 450 gal. New depth 6 in.
Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N 8 type) N If yes, give date
D. LIFT STATION
Date installed NIA Size in gallons Manhole/Access (Y/N)
'Pump on' level at _ in. 'Pump ofr level at_ in. High water alarm level at in.
Datum Cycles tested Meats alarm & circuit requirements?
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot
—Absorpdon'ffeld-on krt _ _�..... ._ ..�_.W._.
Public sewer main
Sewer /septic service line
On adjacent lots 200+
Onadjacerrt-IM___.__----200+'._,
Public sewer manhole/cleanout N/A
Holding tank
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 101+ Property line 10'+ Absorption field 101+
Water main 25'+ Water service line 251+ Surface water 1001+
Wells on adjacent lots 2001+
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 101+ Building foundation 10'+ Water main 251+
Water Service line 25'+ Surface water 1001+ Driveway, parkingivehide storage 251+
Curtain drain 100'+ Wells on adjacent lots 2001+
F. COMMENTS
G. ENGINEER'S CERTIFICATION
1 certify that I have determined through field inspections and
review of Municipal records that the above systems are in
conformance with MOA HAA guidelines in effect on this date.
Engineer's Printed Name Kenneth M. Duffus
HAA Fee $ 430.00 -11 ;tG •CD L kaw Waiver Fee $
Data of Payment (`d, II05
Receipt Number �q
(Rev. 12/01)
Date of Payment
Receipt Number
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I HEREBY CERTIFY -THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY -
AND THAT NO E.NCRO CHM€NTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
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I HEREBY CERTIFY -THAT I HAVE SURVEYED THE
FOLLOWING DESCRIBED PROPERTY -
AND THAT NO E.NCRO CHM€NTS EXIST EXCEPT AS
INDICATED. IT IS THE RESPONSIBILITY OF THE
OWNER TO DETERMINE THE EXISTENCE OF ANY
EASEMENTS, COVENANTS, OR RESTRICTIONS
WHICH DO NOT APPEAR ON THE RECORDED SUBDI-
VISION PLAT. UNDER NO CIRCUMSTANCES SHOULD
ANY DATA HEREON BE USED FOR CONSTRUCTION
OF FENCE LINES, OR FOR ESTABLISHING BOUND-
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MUNICIPALITY OF ANCHORAGE
• '� DEPARTMENT OF HEALTH & HUMAN SERVICES
Division of Environmental Services Ak
On-Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING`
Parcel I.D. # G — 3 HAA # _�/1 1 �`
1. GENERAL INFORMATION
Complete legal description -t-S k_ Z
Location (site address or directions)
Property owner G��tc ltas�� Cc��'YZLCi�cO �� Day phone
Mailing address 3 7 l e- 1�t t/�✓
Lending agency Day phone
Mailing address
Agent Day phone
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3. TYPE OF WATER SUPPLY:
Individual well _
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site
Holding tank
Community on-site
Public sewer _
NOTE: If community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (Ray. 1/91) Front MOA e21
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm !<(%D Engineering Phone
r.441 Ptarmigan Blvd.
Address Eagle �rver, AK 99577-8736
Engineer's signature' �j Date
6. DHHS SIGNATURE
x Approved for bedrooms.
Disapproved.
Conditional approval for
Additional Comments
By:
al1TIC
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Kenne)h Mr D s' W
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bedrooms, with the following stipulations:
Date /a -B - 79
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given in paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-M (P v.1/91) Back MOA k21
Municipality of Anchorage o :7 U 5 1S9
DEPARTMENT OF HEALTH & HUMAN SERVICES MUNI VAL11r (A
Environmental Services Division " UNMFNrAtsFkvic
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907) 343-4744
Health Authority Approval Checklist
Legal Description; __ Parcel LD.: U 3
A. WELL DATA
Well type AJ�ij &4 If A, B, or C, attach ADEC letter. ADEC water system number
Log present (Y/N)
Total depth
Sanitary seal (Y/N)
Date of test
Static water level
Well production
Date completed
Cased
FROM WELL
Casing height (above ground)
Wires properly protected (Y/N)
AT 1\IM 111"•/1T1/\\1
WATER SAMPLE RESULTS:
Coliform Nitrate Other bacteria
Date of sample: Colle ed by:
B. SEPTIC/HOLDING TANK DATA
Date installed Tank size 1000 Number of Compartments Cleanouts (Y/N) y _
Foundation cleanout (Y/N/) Depression (Y/N) _ High water alarm (Y/N) . AIA
Date of Pumping /U Ar Pumper
C. ABSORPTION FIELD DATA
Date installed Soil rating (g.p.d./ft2 or ft2/bdrm) System type 4�
€ t
Lengthg Q I' Width T� Gravel thickness below pipe _ Li _ Total depth _
Effective absorption area Monitoring Tube present (Y/N)Depression over field (Y/N)
Date of adequacy test __
Fluid depth in absorption
Fluid depth
Peroxide
72-026 (Rev. 3/96)*
Results (Pass/Fail)
test (in.);
Minutes later:
(past 12 months) (YM) _
For
!pdiateiy after_ gal. water
Absorption rate =
_ If yes, give date
(in.):
D. LIFT STATION
Date installed
Manhole/Access (Y/N) _
High water alarm level at*
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
"Pump on" level at*
*Datum
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic/holding tank on lot
Absorption field on lot
Public sewer main
Sewer /septic service line
0
A
off" level at*
r
On adjacent lots `-
On adjacent lots
Z 00 f -I-
/VA Public sewer manhole/cleanout NA
Lift station
/J /I
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Foundation /O f Property line / U F Absorption field
Water main/service line 25 4 Surface water/drainage 00 �� Wells on adjacent lots ZOO
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line 10,4 Building foundation /D r�- Water main/service line Z6 r4
Surface water /D U r4
Driveway, parking/vehicle storage area 2-5 -4-
Curtain drain /00 , + Wells on adjacent lots ZUU '4
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review of Municipal
in conformance with OA HAA guidelines in effect on this date.
Signature
Engineer's Name en/2e GI /ti
Date
HAA Fee $ 6D 1 67
Date of Payment
Receipt Number � � 0
72-026 (Rev. 3/96)*
Waiver Fee $
re
Date of Payment
Receipt Number